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Mrochen A, Alhaj Omar O, Pelz JO, Michalski D, Neugebauer H, Lehrieder D, Knier B, Ringmaier C, Stetefeld H, Schönenberger S, Chen M, Schneider H, Alonso A, Lesch H, Totzek A, Erdlenbruch F, Hiller B, Diel NJ, Worm A, Claudi C, Gerner ST, Huttner HB, Schramm P. Guideline-recommended basic parameter adherence in neurocritical care stroke patients: Observational multicenter individual participant data analysis. Eur Stroke J 2024:23969873241289360. [PMID: 39397354 DOI: 10.1177/23969873241289360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2024] Open
Abstract
INTRODUCTION Neurocritical care patients with neurovascular disease often face poor long-term outcomes, highlighting the pivotal role of evidence-based interventions. Although International Guidelines emphasize managing basic physiological parameters like temperature, blood glucose, blood pressure, and oxygen levels, physician adherence to these targets remains uncertain. This study aimed to assess adherence to guideline-based treatment targets for basic physiological parameters in neurocritical care. PATIENTS AND METHODS This multicenter observational study was conducted across eight tertiary University Hospitals in Germany analyzed 474 patients requiring mechanical ventilation (between January 1st and December 31st, 2021). Adherence was defined as the rate of measurements within therapeutic ranges for systolic blood pressure (situation-adapted), mean blood pressure (MAP, 60-90 mmHg), glucose levels (80-180 mg/dl), body temperature (<37.5°C), partial arterial pressure of oxygen (PaO2) 80-120 mmHg und partial arterial pressure of carbon dioxide (PaCO2) 35-45 mmHg during the initial 96 h of hospitalization in 4 hour-intervals. RESULTS Overall, 70.7% of all measurements were within the predetermined therapeutic ranges including SBP (71.3%), temperature (68.3%), MAP (71.4%), PaO2 (65.2%), PaCO2 (75.0%) and blood glucose (80.7%). DISCUSSION AND CONCLUSION This multicenter study demonstrates adherence to guideline-based treatment targets, underscoring the high standards maintained by neurological intensive care units. Our study offers valuable insights into adherence to guideline-based treatment targets for neurocritical care patients in Germany. To improve patient care and optimize therapeutic strategies in neurovascular diseases, further research is needed to examine the impact of these adherence parameters on long-term outcomes.
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Affiliation(s)
- Anne Mrochen
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
| | - Omar Alhaj Omar
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
| | - Johann O Pelz
- Department of Neurology, University Hospital of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital of Leipzig, Leipzig, Germany
| | | | | | - Benjamin Knier
- Department of Neurology, Technical University of Munich School of Medicine, Munich, Germany
| | - Corinna Ringmaier
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
- Medical Faculty, University of Technology, Dresden, Germany
| | - Angelika Alonso
- Department of Neurology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hendrik Lesch
- Department of Neurology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Andreas Totzek
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Friedrich Erdlenbruch
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Benedikt Hiller
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
| | - Norma J Diel
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
| | - André Worm
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
| | - Christian Claudi
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
| | - Stefan T Gerner
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
- Center of Mind, Brain and Behavior (CMBB), Marburg, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
- Center of Mind, Brain and Behavior (CMBB), Marburg, Germany
| | - Patrick Schramm
- Department of Neurology, Justus-Liebig-University, Giessen, Germany
- Translational Neuroscience Network Giessen (TNNG), Giessen, Germany
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Wang A, Meng X, Chen Q, Chu Y, Zhou Q, Jiang D, Wang Z. Efficacy analysis of mechanical thrombectomy combined with prolonged mild hypothermia in the treatment of acute middle cerebral artery occlusion: a single-center retrospective cohort study. Front Neurol 2024; 15:1406293. [PMID: 39045428 PMCID: PMC11263112 DOI: 10.3389/fneur.2024.1406293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 06/20/2024] [Indexed: 07/25/2024] Open
Abstract
Objective To determine the efficacy of mechanical thrombectomy combined with prolonged mild hypothermia compared with conventional treatment in managing acute middle cerebral artery occlusion, and to explore whether extending the duration of hypothermia can improve neurological function. Method From 2018 to June 2023, a retrospective analysis was conducted on 45 patients with acute middle cerebral artery occlusion treated at the NICU of Suzhou Kowloon Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. After thrombectomy, patients were admitted to the neurological intensive care unit (NICU) for targeted temperature management. Patients were divided into two groups: the mild hypothermia group (34.5-35.9°C) receiving 5-7 days of treatment, and the normothermia group (control group) whose body temperature was kept between 36 and 37.5°C using pharmacological and physical cooling methods. Baseline characteristics and temperature changes were compared between the two groups of patients. The primary outcome was the modified Rankin Scale (mRS) score at 3 month after surgery, and the secondary outcomes were related complications and mortality rate. Prognostic risk factors were investigated using both univariate and multivariate logistic regression analyses. Results Among 45 patients, 21 underwent prolonged mild hypothermia, and 24 received normothermia, with no significant differences in baseline characteristics between the two groups. The duration of mild hypothermia ranged from 5 to 7 days. The incidence of chills (33.3% vs. 8.3%, p = 0.031) and constipation (57.1% vs. 20.8%, p = 0.028) was significantly higher in the mild hypothermia group compared with the control group. There was no significant difference in mortality rates between the mild hypothermia and the control group (4.76% vs. 8.33%, p = 1.000, OR = 1.75, 95% CI, 0.171-17.949). At 3 month, there was no significant difference in the modified mRS (0-3) score between the mild hypothermia and control groups (52.4% vs. 25%, p = 0.114, OR = 0.477, 95% CI, 0.214-1.066). Infarct core volume was an independent risk factor for adverse neurological outcomes. Conclusion Prolonged mild hypothermia following mechanical thrombectomy had no severe complications and shows a trend to improve the prognosis of neurological function. The Infarct core volume on CTP was an independent risk factor for predicting neurological function.
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Affiliation(s)
- Anqi Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - Xuan Meng
- Department of Neurosurgery, Suzhou BOE Hospital, Suzhou, China
| | - Qin Chen
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - YanFei Chu
- Department of Neurosurgery, Suzhou BOE Hospital, Suzhou, China
| | - Qiang Zhou
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - DongYi Jiang
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, China
| | - Zhimin Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024; 48:341-355. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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Lee S, Kim M, Kwon MY, Kwon SM, Ko YS, Chung Y, Park W, Park JC, Ahn JS, Jeon H, Im J, Kim JH. The efficacy of therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Acute Crit Care 2024; 39:282-293. [PMID: 38863359 PMCID: PMC11167421 DOI: 10.4266/acc.2024.00612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed. RESULTS The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups. CONCLUSIONS TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.
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Affiliation(s)
- Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Young San Ko
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Yeongu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanwool Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihyun Im
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
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Pelz JO, Kenda M, Alonso A, Etminan N, Wittstock M, Niesen WD, Lambeck J, Güresir E, Wach J, Lampmannn T, Dziewas R, Wiedmann M, Schneider H, Bayas A, Christ M, Mengel A, Poli S, Brämer D, Lindner D, Pfrepper C, Roth C, Salih F, Günther A, Michalski D. Outcomes After Decompressive Surgery for Severe Cerebral Venous Sinus Thrombosis Associated or Not Associated with Vaccine-Induced Immune Thrombosis with Thrombocytopenia: A Multicenter Cohort Study. Neurocrit Care 2024; 40:621-632. [PMID: 37498459 PMCID: PMC10959787 DOI: 10.1007/s12028-023-01782-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/09/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Clinical observations indicated that vaccine-induced immune thrombosis with thrombocytopenia (VITT)-associated cerebral venous sinus thrombosis (CVST) often has a space-occupying effect and thus necessitates decompressive surgery (DS). While comparing with non-VITT CVST, this study explored whether VITT-associated CVST exhibits a more fulminant clinical course, different perioperative and intensive care unit management, and worse long-term outcome. METHODS This multicenter, retrospective cohort study collected patient data from 12 tertiary centers to address priorly formulated hypotheses concerning the clinical course, the perioperative management with related complications, extracerebral complications, and the functional outcome (modified Rankin Scale) in patients with VITT-associated and non-VITT CVST, both with DS. RESULTS Both groups, each with 16 patients, were balanced regarding demographics, kind of clinical symptoms, and radiological findings at hospital admission. Severity of neurological symptoms, assessed with the National Institute of Health Stroke Scale, was similar between groups at admission and before surgery, whereas more patients with VITT-associated CVST showed a relevant midline shift (≥ 4 mm) before surgery (100% vs. 68.8%, p = 0.043). Patients with VITT-associated CVST tended to undergo DS early, i.e., ≤ 24 h after hospital admission (p = 0.077). Patients with VITT-associated CVST more frequently received platelet transfusion, tranexamic acid, and fibrinogen perioperatively. The postoperative management was comparable, and complications were evenly distributed. More patients with VITT-associated CVST achieved a favorable outcome (modified Rankin Scale ≤ 3) at 3 months (p = 0.043). CONCLUSIONS Although the prediction of individual courses remains challenging, DS should be considered early in VITT-associated CVST because an overall favorable outcome appears achievable in these patients.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Martin Kenda
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Wolf-Dirk Niesen
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Wach
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Tim Lampmannn
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck, Osnabrueck, Germany
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
- Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antonios Bayas
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Monika Christ
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Dirk Brämer
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Haemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Farid Salih
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Binda DD, Baker MB, Varghese S, Wang J, Badenes R, Bilotta F, Nozari A. Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review. J Clin Med 2024; 13:586. [PMID: 38276093 PMCID: PMC10816923 DOI: 10.3390/jcm13020586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.
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Affiliation(s)
- Dhanesh D. Binda
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Maxwell B. Baker
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Shama Varghese
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Jennifer Wang
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I Teaching Hospital, Sapienza University of Rome, 00185 Rome, Italy;
| | - Ala Nozari
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
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Liu G, Tian F, Zhu Y, Jiang M, Cui L, Zhang Y, Wang Y, Su Y. The predictive value of EEG reactivity by electrical stimulation and quantitative analysis in critically ill patients with large hemispheric infarction. J Crit Care 2023; 78:154358. [PMID: 37329762 DOI: 10.1016/j.jcrc.2023.154358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/05/2023] [Accepted: 06/02/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The intensive care of critically ill patients with large hemispheric infarction improves the survival rate. However, established prognostic markers for neurological outcome show variable accuracy. We aimed to assess the value of electrical stimulation and quantitative analysis of EEG reactivity for early prognostication in this critically ill population. MATERIALS AND METHODS We prospectively enrolled consecutive patients between January 2018 and December 2021. EEG reactivity was randomly performed by pain or electrical stimulation via visual and quantitative analysis. Neurological outcome within 6-month was dichotomized as good (modified Rankin Scale, mRS 0-3) or poor (mRS 4-6). RESULTS Ninety-four patients were admitted, and 56 were included in the final analysis. EEG reactivity using electrical stimulation was superior to pain stimulation for good outcome prediction (visual analysis: AUC 0.825 vs. 0.763, P = 0.143; quantitative analysis: AUC 0.931 vs. 0.844, P = 0.058). The AUC of EEG reactivity by pain stimulation with visual analysis was 0.763, which increased to 0.931 by electrical stimulation with quantitative analysis (P = 0.006). When using quantitative analysis, the AUC of EEG reactivity increased (pain stimulation 0.763 vs. 0.844, P = 0.118; electrical stimulation 0.825 vs. 0.931, P = 0.041). CONCLUSION EEG reactivity by electrical stimulation and quantitative analysis seems a promising prognostic factor in these critical patients.
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Affiliation(s)
- Gang Liu
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Fei Tian
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yu Zhu
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Mengdi Jiang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Lili Cui
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yan Zhang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yuan Wang
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
| | - Yingying Su
- Neurocritical Care Unit, Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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9
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Macha K, Schwab S. It is all about timing: decompressive hemicraniectomy for malignant middle-cerebral-artery infarction. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:327-328. [PMID: 37160135 PMCID: PMC10169221 DOI: 10.1055/s-0043-1768674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Kosmas Macha
- Friedrich-Alexander-University of Erlangen-Nuremberg, University Hospital Erlangen, Department of Neurology, Erlangen, Germany.
| | - Stefan Schwab
- Friedrich-Alexander-University of Erlangen-Nuremberg, University Hospital Erlangen, Department of Neurology, Erlangen, Germany.
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10
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Shichita T, Ooboshi H, Yoshimura A. Neuroimmune mechanisms and therapies mediating post-ischaemic brain injury and repair. Nat Rev Neurosci 2023; 24:299-312. [PMID: 36973481 DOI: 10.1038/s41583-023-00690-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/29/2023]
Abstract
The nervous and immune systems control whole-body homeostasis and respond to various types of tissue injury, including stroke, in a coordinated manner. Cerebral ischaemia and subsequent neuronal cell death activate resident or infiltrating immune cells, which trigger neuroinflammation that affects functional prognosis after stroke. Inflammatory immune cells exacerbate ischaemic neuronal injury after the onset of brain ischaemia; however, some of the immune cells thereafter change their function to neural repair. The recovery processes after ischaemic brain injury require additional and close interactions between the nervous and immune systems through various mechanisms. Thus, the brain controls its own inflammation and repair processes after injury via the immune system, which provides a promising therapeutic opportunity for stroke recovery.
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Affiliation(s)
- Takashi Shichita
- Stroke Renaissance Project, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
- Department of Neuroinflammation and Repair, Medical Research Institute, Tokyo Medical and Dental University, Tokyo, Japan.
- Core Research for Evolutionary Medical Science and Technology (CREST), Japan Agency for Medical Research and Development (AMED), Tokyo, Japan.
| | - Hiroaki Ooboshi
- Section of Internal Medicine, Department of Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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11
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Khaing ZZ, Chen JY, Safarians G, Ezubeik S, Pedroncelli N, Duquette RD, Prasse T, Seidlits SK. Clinical Trials Targeting Secondary Damage after Traumatic Spinal Cord Injury. Int J Mol Sci 2023; 24:3824. [PMID: 36835233 PMCID: PMC9960771 DOI: 10.3390/ijms24043824] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Spinal cord injury (SCI) often causes loss of sensory and motor function resulting in a significant reduction in quality of life for patients. Currently, no therapies are available that can repair spinal cord tissue. After the primary SCI, an acute inflammatory response induces further tissue damage in a process known as secondary injury. Targeting secondary injury to prevent additional tissue damage during the acute and subacute phases of SCI represents a promising strategy to improve patient outcomes. Here, we review clinical trials of neuroprotective therapeutics expected to mitigate secondary injury, focusing primarily on those in the last decade. The strategies discussed are broadly categorized as acute-phase procedural/surgical interventions, systemically delivered pharmacological agents, and cell-based therapies. In addition, we summarize the potential for combinatorial therapies and considerations.
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Affiliation(s)
- Zin Z. Khaing
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
| | - Jessica Y. Chen
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Gevick Safarians
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Sohib Ezubeik
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Nicolas Pedroncelli
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Rebecca D. Duquette
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
| | - Tobias Prasse
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50931 Cologne, Germany
| | - Stephanie K. Seidlits
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
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12
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Battaglini D, da Silva AL, Felix NS, Rodrigues G, Antunes MA, Rocha NN, Capelozzi VL, Morales MM, Cruz FF, Robba C, Silva PL, Pelosi P, Rocco PRM. Mild hypothermia combined with dexmedetomidine reduced brain, lung, and kidney damage in experimental acute focal ischemic stroke. Intensive Care Med Exp 2022; 10:53. [PMID: 36529842 PMCID: PMC9760586 DOI: 10.1186/s40635-022-00481-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Sedatives and mild hypothermia alone may yield neuroprotective effects in acute ischemic stroke (AIS). However, the impact of this combination is still under investigation. We compared the effects of the combination of mild hypothermia or normothermia with propofol or dexmedetomidine on brain, lung, and kidney in experimental AIS. AIS-induced Wistar rats (n = 30) were randomly assigned, after 24 h, to normothermia or mild hypothermia (32-35 °C) with propofol or dexmedetomidine. Histologic injury score and molecular biomarkers were evaluated not only in brain, but also in lung and kidney. Hemodynamics, ventilatory parameters, and carotid Doppler ultrasonography were analyzed for 60 min. RESULTS In brain: (1) hypothermia compared to normothermia, regardless of sedative, decreased tumor necrosis factor (TNF)-α expression and histologic injury score; (2) normothermia + dexmedetomidine reduced TNF-α and histologic injury score compared to normothermia + propofol; (3) hypothermia + dexmedetomidine increased zonula occludens-1 expression compared to normothermia + dexmedetomidine. In lungs: (1) hypothermia + propofol compared to normothermia + propofol reduced TNF-α and histologic injury score; (2) hypothermia + dexmedetomidine compared to normothermia + dexmedetomidine reduced histologic injury score. In kidneys: (1) hypothermia + dexmedetomidine compared to normothermia + dexmedetomidine decreased syndecan expression and histologic injury score; (2) hypothermia + dexmedetomidine compared to hypothermia + propofol decreased histologic injury score. CONCLUSIONS In experimental AIS, the combination of mild hypothermia with dexmedetomidine reduced brain, lung, and kidney damage.
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Affiliation(s)
- Denise Battaglini
- grid.410345.70000 0004 1756 7871Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy ,grid.5841.80000 0004 1937 0247Department of Medicine, University of Barcelona, 08007 Barcelona, Spain ,grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Adriana Lopes da Silva
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Nathane Santanna Felix
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Gisele Rodrigues
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Mariana Alves Antunes
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Nazareth Novaes Rocha
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil ,grid.411173.10000 0001 2184 6919Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Niterói, 24220-900 Brazil
| | - Vera Luiza Capelozzi
- grid.11899.380000 0004 1937 0722Department of Pathology, University of São Paolo, São Paolo, 05508-060 Brazil
| | - Marcelo Marcos Morales
- grid.8536.80000 0001 2294 473XLaboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, 21941-901 Brazil
| | - Fernanda Ferreira Cruz
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil
| | - Paolo Pelosi
- grid.410345.70000 0004 1756 7871Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia Rieken Macedo Rocco
- grid.8536.80000 0001 2294 473XLaboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Centro de Ciências da Saúde, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ 21941-902 Brazil ,grid.452991.20000 0000 8484 4876Rio de Janeiro Network On Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
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13
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You JS, Kim JY, Yenari MA. Therapeutic hypothermia for stroke: Unique challenges at the bedside. Front Neurol 2022; 13:951586. [PMID: 36262833 PMCID: PMC9575992 DOI: 10.3389/fneur.2022.951586] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022] Open
Abstract
Therapeutic hypothermia has shown promise as a means to improving neurological outcomes at several neurological conditions. At the clinical level, it has been shown to improve outcomes in comatose survivors of cardiac arrest and in neonatal hypoxic ischemic encephalopathy, but has yet to be convincingly demonstrated in stroke. While numerous preclinical studies have shown benefit in stroke models, translating this to the clinical level has proven challenging. Major obstacles include cooling patients with typical stroke who are awake and breathing spontaneously but often have significant comorbidities. Solutions around these problems include selective brain cooling and cooling to lesser depths or avoiding hyperthermia. This review will cover the mechanisms of protection by therapeutic hypothermia, as well as recent progress made in selective brain cooling and the neuroprotective effects of only slightly lowering brain temperature. Therapeutic hypothermia for stroke has been shown to be feasible, but has yet to be definitively proven effective. There is clearly much work to be undertaken in this area.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Youl Kim
- Department of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Midori A. Yenari
- Department of Neurology, The San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Midori A. Yenari
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14
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Ghozy S, Reda A, Varney J, Elhawary AS, Shah J, Murry K, Sobeeh MG, Nayak SS, Azzam AY, Brinjikji W, Kadirvel R, Kallmes DF. Neuroprotection in Acute Ischemic Stroke: A Battle Against the Biology of Nature. Front Neurol 2022; 13:870141. [PMID: 35711268 PMCID: PMC9195142 DOI: 10.3389/fneur.2022.870141] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/21/2022] [Indexed: 12/22/2022] Open
Abstract
Stroke is the second most common cause of global death following coronary artery disease. Time is crucial in managing stroke to reduce the rapidly progressing insult of the ischemic penumbra and the serious neurologic deficits that might follow it. Strokes are mainly either hemorrhagic or ischemic, with ischemic being the most common of all types of strokes. Thrombolytic therapy with recombinant tissue plasminogen activator and endovascular thrombectomy are the main types of management of acute ischemic stroke (AIS). In addition, there is a vital need for neuroprotection in the setting of AIS. Neuroprotective agents are important to investigate as they may reduce mortality, lessen disability, and improve quality of life after AIS. In our review, we will discuss the main types of management and the different modalities of neuroprotection, their mechanisms of action, and evidence of their effectiveness after ischemic stroke.
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Affiliation(s)
- Sherief Ghozy
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States.,Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), Oxford University, Oxford, United Kingdom
| | - Abdullah Reda
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Joseph Varney
- School of Medicine, American University of the Caribbean, Philipsburg, Sint Maarten
| | | | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Mohamed Gomaa Sobeeh
- Faculty of Physical Therapy, Sinai University, Cairo, Egypt.,Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Sandeep S Nayak
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, New York, NY, United States
| | - Ahmed Y Azzam
- Faculty of Medicine, October 6 University, Giza, Egypt
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic Rochester, Rochester, MN, United States
| | | | - David F Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States
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15
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Zhang W, Li F, Zhang C, Lei B, Deng W, Zeng H, Yu Y, Wu J, Peng D, Tian Z, Zhu X, Hu Z, Hong Y, Li W, Ge H, Xu X, Ju D, Yang S, Pan C, Zi W, Wang S. Impact of Body Temperature in Patients With Acute Basilar Artery Occlusion: Analysis of the BASILAR Database. Front Neurol 2022; 13:907410. [PMID: 35720074 PMCID: PMC9205153 DOI: 10.3389/fneur.2022.907410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA link between body temperature and stroke outcomes has been established but not for acute basilar artery occlusion. We aimed to determine the association between body temperature and clinical outcomes in patients with acute basilar artery occlusion and temperature management range.MethodsWe included patients from the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR) database with records of both admission body temperature (ABT) and peak body temperature (PBT). ABT was defined as the body temperature first measured at the hospital visit, PBT was defined as the highest temperature within 24 h of treatment, and minus body temperature (MBT) was defined as PBT-ABT. The primary clinical outcome was favorable functional outcome, defined as the proportion of patients with a modified Rankin Scale score of 0–3 at 3 months. Secondary outcomes included 3-month mortality, in-hospital mortality, and symptomatic cerebral hemorrhage.ResultsA total of 664 patients were enrolled in the study; 74.7% were men, with a median age of 65 (interquartile range, 57.25–74) years. In all patients, multivariate analysis indicated that PBT and MBT were independent predictors of favorable functional outcome [odds ratio (OR), 0.57 (95% CI, 0.43–0.77); OR, 0.68 (95% CI, 0.52–0.88), respectively], and higher ABT, PBT, and MBT were associated with an increased 3-month mortality [OR, 1.47 (95% CI, 1.03–2.10), OR, 1.58 (95% CI, 1.28–1.96), OR, 1.35 (95% CI, 1.11–1.65), respectively]. Proportional odds models demonstrated that when ABT, PBT, MBT were in the range of <37.5, <38.9, and −0.6–2.7°C, respectively, the benefit of the endovascular treatment is clearly greater than that of standard medical treatment in terms of favorable functional outcome.ConclusionsBody temperature is an independent predictor of clinical outcome in patients with acute basilar artery occlusion. It is necessary to control the patient body temperature within the appropriate range in clinical settings.Trial RegistrationChinese Clinical Trial Registry ChiCTR1800014759. Registered 03 February 2018. Retrospectively registered.
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Affiliation(s)
- Wenbin Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Cai Zhang
- Department of Neurology, Daqing Oilfield General Hospital, Daqing, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Zhenxuan Tian
- Department of Neurology, The 404th Hospital of Mianyang, Mianyang, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Zhizhou Hu
- Department of Neurology, Longyan No. 1 Hospital, Longyan, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Wenbo Li
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Wenjie Zi
| | - Shouchun Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Shouchun Wang
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16
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Alonso-Alonso ML, Sampedro-Viana A, Rodríguez-Yáñez M, López-Dequidt I, Pumar JM, Mosqueira AJ, Ouro A, Ávila-Gómez P, Sobrino T, Campos F, Castillo J, Hervella P, Iglesias-Rey R. Antihyperthermic Treatment in the Management of Malignant Infarction of the Middle Cerebral Artery. J Clin Med 2022; 11:jcm11102874. [PMID: 35629002 PMCID: PMC9146428 DOI: 10.3390/jcm11102874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Malignant infarction of the middle cerebral artery (m-MCA) is a complication of ischemic stroke. Since hyperthermia is a predictor of poor outcome, and antihyperthermic treatment is well tolerated, our main aim was to analyze whether the systemic temperature decrease within the first 24 h was associated with a better outcome. Furthermore, we studied potential biochemical and neuroimaging biomarkers. This is a retrospective observational analysis that included 119 patients. The temperature variations within the first 24 h were recorded. Biochemical laboratory parameters and neuroimaging variables were also analyzed. The temperature increase at the first 24 h (OR: 158.97; CI 95%: 7.29−3465.61; p < 0.001) was independently associated with a higher mortality. Moreover, antihyperthermic treatment (OR: 0.08; CI 95%: 0.02−0.38; p = 0.002) was significantly associated with a good outcome at 3 months. Importantly, antihyperthermic treatment was associated with higher survival at 3 months (78% vs. 50%, p = 0.003). Significant independently associations between the development of m-MCA and both microalbuminuria (OR: 1.01; CI 95%: 1.00−1.02; p = 0.005) and leukoaraiosis (OR: 3.07; CI 1.84−5.13−1.02; p < 0.0001) were observed. Thus, antihyperthermic treatment within the first 24 h was associated with both a better outcome and higher survival. An increased risk of developing m-MCA was associated with leukoaraiosis and an elevated level of microalbuminuria.
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Affiliation(s)
- Maria Luz Alonso-Alonso
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
| | - Ana Sampedro-Viana
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - Iria López-Dequidt
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - José M. Pumar
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Department of Neuroradiology, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Antonio J. Mosqueira
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Department of Neuroradiology, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Alberto Ouro
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.O.); (T.S.)
| | - Paulo Ávila-Gómez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (P.Á.-G.); (F.C.)
| | - Tomás Sobrino
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.O.); (T.S.)
| | - Francisco Campos
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (P.Á.-G.); (F.C.)
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; (A.S.-V.); (J.M.P.); (A.J.M.); (J.C.)
- Correspondence: (M.L.A.-A.); (P.H.); (R.I.-R.)
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Kung WM, Lin CC, Chen WJ, Jiang LL, Sun YY, Hsieh KH, Lin MS. Anti-Inflammatory CDGSH Iron-Sulfur Domain 2: A Biomarker of Central Nervous System Insult in Cellular, Animal Models and Patients. Biomedicines 2022; 10:biomedicines10040777. [PMID: 35453528 PMCID: PMC9030396 DOI: 10.3390/biomedicines10040777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/05/2023] Open
Abstract
Spinal cord injury (SCI) promotes brain inflammation; conversely, brain injury promotes spinal neuron loss. There is a need to identify molecular biomarkers and therapeutic targets for central nervous system (CNS) injury. CDGSH iron-sulfur structural domain 2 (CISD2), an NF-κB antagonist, is downregulated after injury in vivo and in vitro. We aimed to examine the diagnostic value of CISD2 in patients with CNS insult. Plasma and cerebrospinal fluid (CSF) CISD2 levels were decreased in 13 patients with CNS insult and were negatively correlated with plasma IL6 levels (associated with disease severity; r = −0.7062; p < 0.01). SCI-induced inflammatory mediators delivered through CSF promoted mouse brain inflammation at 1 h post-SCI. Anti-CISD2 antibody treatment exacerbated SCI-induced inflammation in mouse spine and brain. Lipopolysaccharide-stimulated siCISD2-transfected EOC microglial cells exhibited proinflammatory phenotypes (enhanced M1 polarization, decreased M2 polarization, and increased intranuclear NF-κB p65 translocation). Plasma and CSF CISD2 levels were increased in three patients with CNS insult post-therapeutic hypothermia. CISD2 levels were negatively correlated with plasma and CSF levels of inflammatory mediators. CISD2 inhibition and potentiation experiments in cells, animals, and humans revealed CISD2 as a biomarker for CNS insult and upregulation of CISD2 anti-inflammatory properties as a potential therapeutic strategy for CNS insult.
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Affiliation(s)
- Woon-Man Kung
- Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan;
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei 11114, Taiwan
| | - Chai-Ching Lin
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan; (C.-C.L.); (W.-J.C.); (L.-L.J.)
| | - Wei-Jung Chen
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan; (C.-C.L.); (W.-J.C.); (L.-L.J.)
| | - Li-Lin Jiang
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan; (C.-C.L.); (W.-J.C.); (L.-L.J.)
| | - Yu-Yo Sun
- Institute of Biopharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung 804201, Taiwan;
- Department of Neuroscience, Center for Brain Immunology and Glia (BIG), University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Kuang-Hui Hsieh
- Department of Laboratory Service, Kuang Tien General Hospital, Taichung 43303, Taiwan;
| | - Muh-Shi Lin
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan; (C.-C.L.); (W.-J.C.); (L.-L.J.)
- Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung 43303, Taiwan
- Department of Biotechnology, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
- Department of Health Business Administration, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
- Correspondence:
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Gonzales NR, Grotta JC. Pharmacologic Modification of Acute Cerebral Ischemia. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00057-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Garcia-Estrada E, Morales-Gómez JA, Romero-González M, Martínez-Ortíz RG, García-Hernández MA, Ramos-Delgado CA, López-Hernández PA, Palacios-Ortiz IJ, Martínez-Ponce de León AR. Decompressive Craniectomy for Hemispheric Infarction in a Low-Income Population. World Neurosurg 2021; 156:e152-e159. [PMID: 34517142 DOI: 10.1016/j.wneu.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for poststroke care. Disadvantaged populations show increased incidence, severity, and unfavorable outcomes. This study aimed to report the survival, functional outcome, and caregiver satisfaction of low-income patients diagnosed with a large hemispheric infarction (LHI) who underwent decompressive craniectomy (DC). METHODS A retrospective analysis was conducted in consecutive adult patients with an LHI who underwent DC at a single center between October 2015 and September 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were 1-year survival and favorable functional outcome. RESULTS Forty-nine patients were included; those <60 years of age showed a higher proportion of favorable functional outcomes (76% vs. 33%; P = 0.031) but similar survival (52% vs. 56%; P = 0.645) than older patients, respectively. Performing the craniectomy in <48 hours from stroke onset compared with ≥48 hours showed no statistically significant differences in survival (59% vs. 46%; P = 0.352) and favorable functional outcomes (56% vs. 70%; P = 0.683), respectively. In retrospective thinking, 79% of caregivers would decide to perform the surgery again. CONCLUSIONS Age group and time from stroke onset to craniectomy were not associated with survival; notwithstanding, a higher proportion of patients <60 years of age were associated with a favorable functional outcome compared with older patients. Additionally, if given the option, most caregivers would decide to perform the surgery again, independently of the grade of disability of the patient.
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Affiliation(s)
- Everardo Garcia-Estrada
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Jesús Alberto Morales-Gómez
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
| | - Mariana Romero-González
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Ricardo Gerardo Martínez-Ortíz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Marco Antonio García-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - César Alessandro Ramos-Delgado
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Paúl André López-Hernández
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Isaac Jair Palacios-Ortiz
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Angel Raymundo Martínez-Ponce de León
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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21
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Hartmann C, Winzer S, Pallesen LP, Prakapenia A, Siepmann T, Moustafa H, Theilen H, Barlinn J, Gerber JC, Linn J, Reichmann H, Barlinn K, Puetz V. Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion. Eur J Neurol 2021; 28:2479-2487. [PMID: 33973292 DOI: 10.1111/ene.14906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. METHODS We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3 months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. RESULTS Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76 ± 16 years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p = 0.02) and bradyarrhythmia (52.6% vs. 16.4%, p < 0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). CONCLUSIONS Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.
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Affiliation(s)
- Christian Hartmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Haidar Moustafa
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Hermann Theilen
- Department of Anesthesiology, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
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22
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
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Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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Abstract
Objectives: Concise “synthetic” review of the state of the art of management of acute ischemic stroke. Data Sources: Available literature on PubMed. Study Selection: We selected landmark studies, recent clinical trials, observational studies, and professional guidelines on the management of stroke including the last 10 years. Data Extraction: Eligible studies were identified and results leading to guideline recommendations were summarized. Data Synthesis: Stroke mortality has been declining over the past 6 decades, and as a result, stroke has fallen from the second to the fifth leading cause of death in the United States. This trend may follow recent advances in the management of stroke, which highlight the importance of early recognition and early revascularization. Recent studies have shown that early recognition, emergency interventional treatment of acute ischemic stroke, and treatment in dedicated stroke centers can significantly reduce stroke-related morbidity and mortality. However, stroke remains the second leading cause of death worldwide and the number one cause for acquired long-term disability, resulting in a global annual economic burden. Conclusions: Appropriate treatment of ischemic stroke is essential in the reduction of mortality and morbidity. Management of stroke involves a multidisciplinary approach that starts and extends beyond hospital admission.
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25
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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26
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Fan L, Su Y, Zhang Y, Ye H, Chen W, Liu G. Decompressive craniectomy combined with mild hypothermia in patients with large hemispheric infarction: a randomized controlled trial. BMC Neurol 2021; 21:114. [PMID: 33711963 PMCID: PMC7953537 DOI: 10.1186/s12883-021-02142-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background The effect of hypothermia on large hemispheric infarction (LHI) remains controversial. Our study aimed to explore the therapeutic outcomes of decompressive craniectomy (DC) combined with hypothermia on LHI. Methods Patients were randomly divided into three groups: the DC group, the DC plus head surface cooling (DCSC) group and the DC plus endovascular hypothermia (DCEH) group. The DC group was maintained normothermia. The DCSC group received 24-h ice cap on the head for 7 days. While the DCEH group were given endovascular hypothermia (34 °C). Mortality and modified Rankin Scale (mRS) score at 6 months were evaluated. Results Thirty-four patients were included in the study. Mortality of the DC, DCSC and DCEH groups at discharge were 22.2% (2/9), 0% (0/14) and 9.1% (1/11), respectively. However, it increased to 44.4% (4/9), 21.4% (3/14) and 45.5% (5/11) at 6 months, respectively (p = 0.367). Pneumonia (8 cases) was the leading cause of death after discharge. Twelve cases (35.3%) achieved good neurological outcome (mRS 0–3) at 6 months. The proportions of good neurological outcome in the DC, DCSC and DCEH groups were 22.2% (2/9 cases), 42.9% (6/14 cases) and 36.4% (4/11), respectively. The DCSC group seemed to have higher proportion of good outcomes, but there was no significant difference between groups (p = 0.598). Among survivors, endovascular hypothermia had a higher proportion of good outcome (DC group, 2/5 cases, 40.0%; DCSC group, 6/11 cases, 54.5%; DCEH group, 4/6 cases, 66.7%; p = 0.696). The incidence of complications in the DCEH group was higher than those of the DC and DCSC groups (18.9%, 12.0%, and 12.1%, respectively; p = 0.025). Conclusions There is still no evidence to confirm that hypothermia further reduces long-term mortality and improves neurological outcomes in LHI patients with DC. However, there is a trend to benefit survivors from hypothermia. A local cooling method may be a better option for DC patients, which has little impact on systematic complications. Trial registration Decompressive Hemicraniectomy Combined Hypothermia in Malignant Middle Cerebral Artery Infarct, ChiCTR-TRC-12002698. Registered 11 Oct 2012- Retrospectively registered, URL: http://www.chictr.org.cn/showproj.aspx?proj=6854.
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Affiliation(s)
- Linlin Fan
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hong Ye
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Gang Liu
- Department of Neurology, Xuanwu Hospital Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
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Moustafa H, Schoene D, Altarsha E, Rahmig J, Schneider H, Pallesen LP, Prakapenia A, Siepmann T, Barlinn J, Passauer J, Reichmann H, Puetz V, Barlinn K. Acute kidney injury in patients with malignant middle cerebral artery infarction undergoing hyperosmolar therapy with mannitol. J Crit Care 2021; 64:22-28. [PMID: 33770572 DOI: 10.1016/j.jcrc.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/28/2021] [Accepted: 02/19/2021] [Indexed: 12/09/2022]
Abstract
PURPOSE To assess the kidney safety profile of mannitol in patients with malignant middle cerebral artery (MCA) infarction. MATERIAL AND METHODS We studied consecutive patients with malignant MCA infarction (01/2008-01/2018). Malignant MCA infarction was defined according to DESTINY criteria. We compared clinical endpoints including acute kidney injury (AKI; according to Kidney Disease: Improving Global Outcomes [KDIGO]) and dialysis between patients with and without mannitol. Multivariable model was built to explore predictor variables of AKI and in-hospital death. RESULTS Overall, 219 patients with malignant MCA infarction were included. Mannitol was administered in 93/219 (42.5%) patients with an average dosage of 650 g (250-950 g). Patients treated with mannitol more frequently suffered from AKI (39.8% vs. 11.9%; p < 0.001) and required hemodialysis (7.5% vs. 0.8%; p = 0.01) than patients without mannitol. At discharge, more patients in the mannitol group had persistent AKI than control patients (23.7% vs. 6.4%, p < 0.001). In multivariable model, mannitol emerged as independent predictor of AKI (OR 5.02, 95%CI 2.36-10.69; p < 0.001). CONCLUSIONS Acute kidney injury appears to be a frequent complication of hyperosmolar therapy with mannitol in patients with malignant MCA infarction. Given the lack of evidence supporting effectiveness of mannitol in these patients, its routine use should be carefully considered.
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Affiliation(s)
- Haidar Moustafa
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Eyad Altarsha
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany; Medical Faculty, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jens Passauer
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Mrosk F, Hecht N, Vajkoczy P. Decompressive hemicraniectomy in ischemic stroke. J Neurosurg Sci 2020; 65:249-258. [PMID: 33252206 DOI: 10.23736/s0390-5616.20.05103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Malignant hemispheric stroke (MHS) is a life-threatening event, associated with high morbidity and mortality. Decompressive hemicraniectomy (DHS) is the treatment of choice to relieve the emerging space-occupying brain edema. This review details the pathophysiological and scientific background, considerations for clinical decision making, surgical treatment and impact on the patients' outcome. Although surgery reduces mortality significantly, the probability for unfavorable outcome is still high in selected cases. While former randomized controlled studies aimed for the prevention of the primary cause, the current research focuses on the treatment and prevention of secondary neurological injury.
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Affiliation(s)
- Friedrich Mrosk
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany -
| | - Peter Vajkoczy
- Department of Neurosurgery, Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Therapeutic Hypothermia in Patients with Malignant Ischemic Stroke and Hemicraniectomy—A Systematic Review and Meta-analysis. World Neurosurg 2020; 141:e677-e685. [DOI: 10.1016/j.wneu.2020.05.277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
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The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy. Neurocrit Care 2020; 34:990-999. [PMID: 32812197 DOI: 10.1007/s12028-020-01069-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND/OBJECTIVE Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. METHODS Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h. RESULTS We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. CONCLUSIONS Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.
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Affiliation(s)
- Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2020; 41:2521-2529. [PMID: 32219592 PMCID: PMC8197712 DOI: 10.1007/s10072-020-04349-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Introduction Noninvasive temperature modulation by localized neck cooling might be desirable in the prehospital phase of acute hypoxic brain injuries. While combined head and neck cooling induces significant discomfort, peripheral vasoconstriction, and blood pressure increase, localized neck cooling more selectively targets blood vessels that supply the brain, spares thermal receptors of the face and skull, and might therefore cause less discomfort cardiovascular side effects compared to head- and neck cooling. The purpose of this study is to assess the effects of noninvasive selective neck cooling on cardiovascular parameters and cerebral blood flow velocity (CBFV). Methods Eleven healthy persons (6 women, mean age 42 ± 11 years) underwent 90 min of localized dorsal and frontal neck cooling (EMCOOLS Brain.Pad™) without sedation. Before and after cooling onset, and after every 10 min of cooling, we determined rectal, tympanic, and neck skin temperatures. Before and after cooling onset, after 60- and 90-min cooling, we monitored RR intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), laser Doppler skin blood flow (SBF) at the index finger pulp, and CBFV at the proximal middle cerebral artery (MCA). We compared values before and during cooling by analysis of variance for repeated measurements with post hoc analysis (significance: p < 0.05). Results Neck skin temperature dropped significantly by 9.2 ± 4.5 °C (minimum after 40 min), while tympanic temperature decreased by only 0.8 ± 0.4 °C (minimum after 50 min), and rectal temperature by only 0.2 ± 0.3 °C (minimum after 60 min of cooling). Index finger SBF decreased (by 83.4 ± 126.0 PU), BPsys and BPdia increased (by 11.2 ± 13.1 mmHg and 8.0 ± 10.1 mmHg), and heart rate slowed significantly while MCA-CBFV remained unchanged during cooling. Conclusions While localized neck cooling prominently lowered neck skin temperature, it had little effect on tympanic temperature but significantly increased BP which may have detrimental effects in patients with acute brain injuries.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Wu L, Wu D, Yang T, Xu J, Chen J, Wang L, Xu S, Zhao W, Wu C, Ji X. Hypothermic neuroprotection against acute ischemic stroke: The 2019 update. J Cereb Blood Flow Metab 2020; 40:461-481. [PMID: 31856639 PMCID: PMC7026854 DOI: 10.1177/0271678x19894869] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability worldwide. Therapeutic hypothermia has long been considered as one of the most robust neuroprotective strategies. Although the neuroprotective effects of hypothermia have only been confirmed in patients with global cerebral ischemia after cardiac arrest and in neonatal hypoxic ischemic encephalopathy, establishing standardized protocols and strictly controlling the key parameters may extend its application in other brain injuries, such as acute ischemic stroke. In this review, we discuss the potential neuroprotective effects of hypothermia, its drawbacks evidenced in previous studies, and its potential clinical application for acute ischemic stroke especially in the era of reperfusion. Based on the different conditions between bench and bedside settings, we demonstrate the importance of vascular recanalization for neuroprotection of hypothermia by analyzing numerous literatures regarding hypothermia in focal cerebral ischemia. Then, we make a thorough analysis of key parameters of hypothermia and introduce novel hypothermic therapies. We advocate in favor of the process of clinical translation of intra-arterial selective cooling infusion in the era of reperfusion and provide insights into the prospects of hypothermia in acute ischemic stroke.
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Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tuo Yang
- Department of Neurology, Pittsburgh Institute of Brain Disorders and Recovery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jin Xu
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Luling Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuaili Xu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Michalski D, Jungk C, Brenner T, Dietrich M, Nusshag C, Weigand MA, Reuß CJ, Beynon C, Bernhard M. Neurologische Intensivmedizin. Anaesthesist 2020; 69:129-136. [DOI: 10.1007/s00101-019-00643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Huber C, Huber M, Ding Y. Evidence and opportunities of hypothermia in acute ischemic stroke: Clinical trials of systemic versus selective hypothermia. Brain Circ 2019; 5:195-202. [PMID: 31950095 PMCID: PMC6950508 DOI: 10.4103/bc.bc_25_19] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022] Open
Abstract
Stroke is the second leading cause of death globally and the third leading cause disability. Acute ischemic stroke (AIS), resulting from occlusion of major vessels in the brain, accounts for approximately 87% of strokes. Despite this large majority, current treatment options for AIS are severely limited and available to only a small percentage of patients. Therapeutic hypothermia (TH) has been widely used for neuroprotection in the setting of global ischemia postcardiac arrest, and recent evidence suggests that hypothermia may be the neuroprotective agent that stroke patients desperately need. Several clinical trials using systemic or selective cooling for TH have been published, reporting the safety and feasibility of these methods. Here, we summarize the major clinical trials of TH for AIS and provide recommendations for future studies.
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Affiliation(s)
- Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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Legriel S. Hypothermia as a treatment in status epilepticus: A narrative review. Epilepsy Behav 2019; 101:106298. [PMID: 31133509 DOI: 10.1016/j.yebeh.2019.04.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 12/19/2022]
Abstract
Status epilepticus (SE) is associated with high mortality and morbidity rates, notably in its refractory and super-refractory forms. This narrative review discusses recent data on the potential benefits of targeted temperature management. In studies of patients with cerebral injury due to various factors, therapeutic hypothermia had variable effects on survival and functional outcomes. Sources of this variability may include the underlying etiology, whether hypothermia was used for prophylaxis or treatment, the degree and duration of hypothermia, and the hypothermia application modalities. Data from animal studies strongly suggest benefits from therapeutic hypothermia in SE. In humans, beneficial effects have been described in anecdotal case reports and small case series, but the level of evidence is low. A randomized controlled trial found no evidence that moderate hypothermia (32-34 °C) was neuroprotective in critically ill patients with convulsive SE. Nevertheless, some promising effects were noted, suggesting that therapeutic hypothermia might have a role as an adjuvant to anticonvulsant drug therapy in patients with refractory or super-refractory SE. This article is part of a Special Issue entitled "Status Epilepticus". This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Stéphane Legriel
- Medico-Surgical Intensive Care Department, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay Cedex, France; Paris Descartes University, Sorbonne Paris Cité-Medical School, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France; IctalGroup, France.
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Outcomes of therapeutic hypothermia in patients treated with decompressive craniectomy for malignant Middle cerebral artery infarction: A systematic review and meta-analysis. Clin Neurol Neurosurg 2019; 188:105569. [PMID: 31710882 DOI: 10.1016/j.clineuro.2019.105569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The beneficial effects of therapeutic hypothermia (TH) after decompressive craniectomy (DC) for malignant middle cerebral artery (MCA) infarction are controversial. We conducted a systematic review and meta-analysis to assess the clinical efficacy of TH in aforementioned patients. PATIENTS AND METHODS A systematic literature search was conducted to find articles published up to April 2019 evaluating the effect of combining TH and DC on short-term (≤30 days) and long-term (>6 months) mortality and neurological outcomes in patients with malignant MCA infarction. Pooled relative risk (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effects model or the DerSimonian-Laird random-effects. RESULTS Patient data was analyzed for a total of 289 patients from four selected studies and two abstracts. Compared to DC alone, combining DC and TH had a tendency to reduce short-term mortality (RR = 0.52, 95% CI 0.26 to 1.05, P = 0.07, I2 = 0%) but had no significant effects on long-term mortality (RR = 1.26, 95% CI 0.58 to 2.76, P = 0.56, I2 = 68%) or neurological outcomes (RR = 0.81, 95% CI 0.53 to 1.24, P = 0.34, I2 = 30%). CONCLUSION Using TH in tandem with DC did not show definite short- or long-term survival benefits in our study, but may tend to reduce the short-term mortality of patients with malignant MCA infarction.
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Neugebauer H, Schneider H, Kollmar R. Letter by Neugebauer et al. regarding article "Hypothermia after decompressive hemicraniectomy in treatment of malignant middle cerebral artery stroke: comment on the randomized clinical trial". Crit Care 2019; 23:315. [PMID: 31530280 PMCID: PMC6749710 DOI: 10.1186/s13054-019-2600-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, University of Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Klinikum Darmstadt, Darmstadt, Germany
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Pelz JO, Fischer MM, Bungert-Kahl P, Lindner D, Fricke C, Michalski D. Fluid Balance Variations During the Early Phase of Large Hemispheric Stroke Are Associated With Patients' Functional Outcome. Front Neurol 2019; 10:720. [PMID: 31333571 PMCID: PMC6616133 DOI: 10.3389/fneur.2019.00720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
Background: From the variety of factors underlying the ischemia-associated edema formation in large hemispheric stroke (LHS), an increased brain water content during the early phase seems to have a pivotal role for long-lasting tissue damage. However, the importance of the fluid management during the acute phase of LHS has so far not been adequately studied. Therefore, this study explored the association between the fluid balance and functional outcome in patients suffering from LHS. Methods: We analyzed hospital-based medical records of 39 consecutive patients with LHS and decompressive hemicraniectomy. Over the first 10 days after admission, the volumes of all administered fluids were assessed daily and corrected for daily urinary output and insensible loss. Functional outcome at 3 months was assessed with the modified Rankin Scale (mRS) and dichotomized into an acceptable (mRS ≤ 4) vs. a poor outcome (mRS ≥ 5). Results: Compared to patients with a poor functional outcome (n = 19), those with an acceptable outcome (n = 20) were characterized by a significantly lower cumulative net fluid balance at day 5 (1.6 ± 2.5 vs. 3.4 ± 4.4 l), day 7 (2.0 ± 2.9 vs. 4.6 ± 5.2 l), and day 10 (0 ± 2.5 vs. 5.6 ± 6.2 l). In addition to age, only the cumulative net fluid balance at day 10 served as an independent factor for poor functional outcome in multiple regression analyses. Conclusion: These data provide evidence for a critical role of the early phase net fluid balance with respect to the functional outcome after LHS. This observation leads to the hypothesis that patients with LHS might benefit from a more restrictive volume therapy. However, prospective studies are warranted to establish a causal relationship and recommendations for treatment strategies.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Peggy Bungert-Kahl
- Neurologisches Rehabilitationszentrum Leipzig, University of Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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Engrand N, Mazighi M, Dinkelacker V. Hypothermia after decompressive hemicraniectomy in treatment of malignant middle cerebral artery stroke: comment on the randomized clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:164. [PMID: 31072354 PMCID: PMC6509844 DOI: 10.1186/s13054-019-2452-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/18/2019] [Indexed: 11/13/2022]
Affiliation(s)
- N Engrand
- Neuro-Intensive Care Unit, Fondation Ophtalmologique Rothschild, 29 rue Manin, 75019, Paris, France.
| | - M Mazighi
- Interventional Neuroradiology Department, Fondation Ophtalmologique Rothschild, 29 rue Manin, 75019, Paris, France
| | - V Dinkelacker
- Neurological Department, Fondation Ophtalmologique Rothschild, 29 rue Manin, 75019, Paris, France
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Kuczynski AM, Demchuk AM, Almekhlafi MA. Therapeutic hypothermia: Applications in adults with acute ischemic stroke. Brain Circ 2019; 5:43-54. [PMID: 31334356 PMCID: PMC6611191 DOI: 10.4103/bc.bc_5_19] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/05/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022] Open
Abstract
The advent of mechanical thrombectomy and increasing alteplase use have transformed the care of patients with acute ischemic stroke. Patients with major arterial occlusions with poor outcomes now have a chance of returning to independent living in more than half of the cases. However, many patients with these severe strokes suffer major disability despite these therapies. The search is ongoing for agents that can be combined with thrombectomy to achieve better recovery through halting infarct growth and mitigating injury after ischemic stroke. Several studies in animals and humans have demonstrated that therapeutic hypothermia (TH) offers potential to interrupt the ischemic cascade, reduce infarct volume, and improve functional independence. We performed a literature search to look up recent advances in the use of TH surrounding the science, efficacy, and feasibility of inducing TH in modern stroke treatments. While protocols remain controversial, there is a real opportunity to combine TH with the existing therapies to improve outcome in adults with acute ischemic stroke.
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Affiliation(s)
| | - Andrew M Demchuk
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
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